A.E.M.B.A Emergency Contact Form

Members Legal Name: 

Date of Birth: _____ / _____ / _____

Blood Type_______________

Name of Contact:

Name of Parent or Guardian (if less than 18): 

Relationship with contact:

Contacts Home Address:

Contacts Home Phone: __________________________  Work Phone: ______________________

If Member is under 18    I grant permission for my child, ________________________________, to attend AEMBA activities throughout the year including

Signature of Parent / Guardian: 

Date: ______________________________

Name of Physician or Clinic:

Address/ Phone Number:

Does member have a dental appliance?

Does member wear contact lenses?

• Does member have any medication that must be kept with him or her
   at all times?
  
  If 'Yes', please explain: 
• Has allergies to:
• Natural Substances (e.g. Bee Stings)
• Medications (e.g. aspirin, penicillin)
• Any other allergy about which it is important for us to know? _____
  If yes, please explain: 
   
•  
• Any medical condition that would demand the immediate attention of an adult?
• If yes, please explain:
   
•  
• Sign___________________________ Print_______________________  Date______________